Healthcare Provider Details

I. General information

NPI: 1356323000
Provider Name (Legal Business Name): MATHEW J COSENZA DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2005
Last Update Date: 01/21/2021
Certification Date: 01/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 PATTONSVILLE RD
JACKSON OH
45640-9452
US

IV. Provider business mailing address

90 JACKSON PIKE
GALLIPOLIS OH
45631-1560
US

V. Phone/Fax

Practice location:
  • Phone: 855-446-5937
  • Fax: 740-395-8834
Mailing address:
  • Phone: 740-446-5418
  • Fax: 740-446-5958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number34006288
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number34006288
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: